Free Statement of Identity for Children Under 18 Years of Age, HCF 10154 - Wisconsin


File Size: 112.8 kB
Pages: 1
Date: October 23, 2008
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHCAA-BOP
Word Count: 232 Words, 1,481 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms/F1/F10154.pdf

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Preview Statement of Identity for Children Under 18 Years of Age, HCF 10154
STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10154 (07/08)

ID

STATEMENT OF IDENTITY FOR CHILDREN UNDER 18 YEARS OF AGE
This Statement may be used only to meet the new Medicaid/BadgerCare Plus/family planning services proof of identity rule for children under 18 years of age. This statement may not be used to meet the Medicaid/BadgerCare Plus /family planning services proof of citizenship rule. Instructions: In the space provided below, list all the children under age 18 in your household for whom you are a parent, guardian or caretaker relative. For each child you list, include the child's date of birth and place of birth (city, state and country). Complete, sign and return this statement to your local Medicaid/BadgerCare Plus office.

Child's Full Name (First, MI, Last) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Date of Birth

Place of Birth (City, State, Country)

Personally identifiable information will be used only for the direct administration of the Medicaid program. By signing this statement, I certify, under penalty of perjury and false swearing, that the information I have given is correct and complete to the best of my knowledge. I understand that the local agency may contact other persons or organizations, to confirm the accuracy of my statement. SIGNATURE (Parent, Guardian or Caretaker Relative) Print Name (Parent, Guardian or Caretaker Relative) Case Number Date Signed

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